Publications by authors named "Marius Molund"

18 Publications

  • Page 1 of 1

The Anatomy and Function of the Individual Bands of the Deltoid Ligament-and Implications for Stability Assessment of SER Ankle Fractures.

Foot Ankle Orthop 2022 Apr 14;7(2):24730114221104078. Epub 2022 Jun 14.

Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway.

Background: Deltoid ligament injury occurs often with supination-external rotation (SER) ankle trauma. SER fibula fractures with concomitant deltoid ligament injury are considered unstable-requiring operative fixation. Recent studies have questioned this general practice with emphasis on better defining the medial side ankle ligamentous injury. The function of the individual bands of the deltoid ligament, and the interplay between them, are not fully understood. We undertook this study to develop a better understanding of these complex ligamentous structures and ultimately aid assessment and treatment choice of SER ankle fractures with concomitant deltoid ligament injuries.

Methods: Ten fresh-frozen cadaveric foot and ankle specimens were studied. We identified the various ligament bands and did a functional analysis by assessment of ligament length and tension at predefined angles of ankle dorsi-plantarflexion combined with valgus/varus and rotation. The results were determined by manual evaluation with calipers and goniometers, manual stress, and direct visualization.

Results: We recorded primarily 5 different bands of the deltoid ligament: the tibionavicular (TNL; 10/10) tibiospring (TSL; 9/10), tibiocalcaneal (TCL; 10/10), deep anterior tibiotalar (dATTL; 9/10), and deep posterior tibiotalar (dPTTL; 10/10) ligaments. The tibiospring ligament was tense in plantarflexion, while the tibiocalcaneal and deep posterior tibiotalar ligaments were tense in dorsiflexion. The superficial layer ligaments and the deep anterior tibiotalar ligament length and tension were largely affected by changes in varus/valgus and rotation. The deep posterior tibiotalar ligament length and tension was altered predominantly by changes in dorsi-plantarflexion; varus/valgus positioning had a minor effect on this band.

Conclusions: We confirmed the finding of previous studies that dorsi-plantarflexion affects the tensile engagement of the separate ligament bands differently. Likewise, combined movements with varus/valgus and rotation seem to affect the separate ligament bands differently. Our results suggest that the TNL, TSL, and dATTL are at risk of injury, whereas the TCL and particularly the dPTTL are protected in the event of an SER-type ankle fracture mechanism of injury.

Level Of Evidence: Level V, cadaveric study.
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http://dx.doi.org/10.1177/24730114221104078DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9201323PMC
April 2022

Proximal Fifth Metatarsal Fractures: A Retrospective Study of 834 Fractures With a Minimum Follow-up of 5 Years.

Foot Ankle Int 2022 05 5;43(5):602-608. Epub 2022 Feb 5.

Sykehust Østfold Trust, Grålum, Norway.

Background: Proximal fifth metatarsal fractures are common fractures. Treatment strategies have been debated. We wanted to investigate whether Lawrence and Botte's classification has prognostic value because of time to fracture union, and evaluate if weightbearing as tolerated (WBAT) and nonweightbearing (NWB) treatment strategy had effect on time to fracture union in nonoperatively treated fractures.

Methods: Computerized database search, patients diagnosed between January 1, 2003, and December 31, 2015.

Results: We identified 834 fractures; 510 (61.2%) zone 1, 157 (18.8%) zone 2, and 167 (20.0%) zone 3. Most (94.4%) were treated nonoperatively; time to fracture union was 7.5 (SD 7.7), 7.7 (5.6), and 9.2 (8.1) weeks for zone 1, 2, and 3, respectively, which gave a significant longer time to union for zone 3 compared to zone 1 fractures ( = .04). There was no difference in time to fracture union when comparing WBAT and NWB for all fracture zones. Failure to union, defined as crossover to surgery and/or delayed union, was found in 13 (2.7%) zone 1, 5 (3.2%) zone 2, and 6 (3.8%) zone 3 fractures. Refracture during follow-up was found in 3 (0.6%) zone 1 and 14 (8.9%) zone 3 fractures.

Conclusion: Proximal fifth metatarsal fractures have high union rates with nonoperative treatment. No difference in time to union could be found between WBAT and NWB treatment strategies for all fracture zones. We observed a significantly longer time to fracture union for zone 3 fractures compared to zone 1 fractures. Refracture occurs in a nonnegligible share of nonoperatively treated zone 3 fractures.
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http://dx.doi.org/10.1177/10711007211069123DOI Listing
May 2022

Weightbearing Stable Bimalleolar Ankle Fractures-Bony Equivalents to the Ligamentous Weber B/SER4a Fracture Type? A Prospective Case Series.

Foot Ankle Orthop 2022 Jan 18;7(1):24730114211068779. Epub 2022 Jan 18.

Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway.

Background: In a recent study, we documented that partially unstable Weber B/SER4a fracture types reach union with preserved normal ankle congruence after treatment with a functional orthosis and weightbearing allowed. In the present article, we present a case series of weightbearing stable bimalleolar fractures treated nonoperatively that extends our previously published research.

Methods: We included 5 patients with primarily nondisplaced bimalleolar ankle fractures that were stable on weightbearing radiographs. Participants were treated with a walking boot or cast with weightbearing allowed. We also provide a qualitative anatomical analysis of fracture morphology on computed tomographic scans.

Results: Median medial clear space (MCS) of fractured ankles after union were 2.4 mm (range, 1.5-3.1). Qualitative descriptions of fracture morphology showed that all fractures were oblique starting at the intercollicular groove of the medial malleolus and extended anteriorly and proximally.

Conclusion: MCS measurements after fracture union of nonoperatively treated weightbearing stable bimalleolar fractures seemed consistent with normative data of ankle congruence in our previous study. We consistently recorded oblique fracture patterns involving the anterior colliculus, leaving the origin of posterior deep deltoid ligament intact. We present our material as an argument for the existence of a bony (bimalleolar) equivalent to the ligamentous SER4a fracture.

Level Of Evidence: Level IV, prospective case series.
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http://dx.doi.org/10.1177/24730114211068779DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8777357PMC
January 2022

Weightbearing Radiographs Reliably Predict Normal Ankle Congruence in Weber B/SER2 and 4a Fractures: A Prospective Case-Control Study.

Foot Ankle Int 2021 09 14;42(9):1097-1105. Epub 2021 Jul 14.

Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway.

Background: In Weber B/SER2-4 ankle fractures, assessment with weightbearing radiographs to ascertain stability of the ankle mortise has been advised. However, no previous studies report whether this method leads to preservation of normal ankle congruence. The purpose is to evaluate equivalence of ankle congruence of injured ankles after fracture union, vs the uninjured side, for stable SER2 and partially unstable SER4a fracture types.

Methods: We conducted a prospective case-control study designed as an equivalence trial to evaluate if weightbearing radiographs predict whether stable/SER2 and partially unstable/SER4a Weber B ankle fractures reach union with preserved normal tibiotalar congruence and without a concomitant increase of treatment failure. A total of 149 patients with a Weber B fracture stable on weightbearing radiographs were recruited into the trial. All participants were treated with a functional orthosis and weightbearing allowed. Results from gravity stress radiographs classified ankles as SER2 or SER4a fracture types. We defined an equivalence margin in medial clear space difference of 1.0 mm. We also evaluated the reliability of obtaining measurements from weightbearing radiographs.

Results: No differences in medial clear space between the injured and uninjured ankles were observed after fracture union for the SER2 group (mean difference 0.1 mm, 95% confidence interval [CI] -0.3, 0.0; = .056), or the SER4a group (mean difference 0.0 mm (95% CI -0.1, 0.1; = .797). No between-group differences were observed (mean difference 0.0 mm, 95% CI -0.2, 0.2; = .842). These findings were consistent with equivalence. CIs for the intraclass correlation coefficients indicated excellent reliability.

Conclusion: Assessment of stability of Weber B SER2/4a ankle fractures, with weightbearing radiographs, also predicts preservation of normal ankle congruence in those deemed stable, with no difference between SER2 and SER4a fracture types. Further, excellent reproducibility of the method of obtaining medial clear space measurements was demonstrated.

Level Of Evidence: Level III, case-control.
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http://dx.doi.org/10.1177/10711007211027286DOI Listing
September 2021

Fibular Rod Osteosynthesis in Ankle Fractures With Compromised Soft Tissue.

Foot Ankle Spec 2021 Jun 18:19386400211018075. Epub 2021 Jun 18.

Department of Orthopaedic Surgery, Ostfold Hospital Trust, Graalum, Norway.

Background: Complications after plate and screw fixation of ankle fractures are frequently reported in the literature, with a higher rate in patients with advanced age, comorbidities, and poor skin conditions. A reduced complication rate has been reported with intramedullary nailing (IMN) of the fibula; however, the indication has been based on the surgeon's preferences. We report the results after IMN in patients with compromised soft tissue exclusively.

Methods: A total of 71 patients with 72 distal fibula fractures were included in this retrospective study. Information about medical history, the ankle injury, treatment, and complications were collected from the medical records. Additionally, the preinjury and 6-week follow-up radiographs were evaluated.

Results: Postoperative information was available for a minimum of 4.3 years postoperatively or until death. In all, 10 patients had complications related to the nail and required secondary surgery. These included 6 symptomatic hardware issues, 2 construct failures, 1 deep infection, and 1 combined deep infection and construct failure.

Conclusions: After IMN of the fibula, 14% of the patients required reoperation. Our results support the previous literature suggesting IMN as an acceptable surgical alternative where the risk of complications with plate and screw fixation is considered too high. Compromised soft tissue is one important indication.

Level Of Evidence: .
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http://dx.doi.org/10.1177/19386400211018075DOI Listing
June 2021

Long-term Functional Outcomes and Complications in Operative Versus Nonoperative Treatment for Displaced Midshaft Clavicle Fractures in Adolescents: A Retrospective Comparative Study.

J Pediatr Orthop 2021 May-Jun 01;41(5):279-283

Department of Orthopaedic Surgery, Østfold Hospital Trust, Grålum, Norway.

Introduction: Traditionally, midshaft clavicular fractures in adolescents are treated nonoperatively. In later years, a trend toward operative treatment can be observed. Documentation of the benefit of surgery in this group is scarce. The purpose of this study is to evaluate the long-term patient reported functional outcomes and complications for patients treated operatively and nonoperatively for displaced midshaft clavicular fractures. Using the same outcomes we also compared the operative methods.

Methods: One hundred nine adolescents aged 12 to 18 years sustaining displaced midshaft clavicular fractures in the period 2010 to 2016 were identified in our computerized files. Sixty-one were treated nonoperatively, 48 operatively (22 plate and 26 intramedullary nail). Their radiographs and patient journals were examined for fracture classification, wound infection, sensory affection, surgery duration, hardware removal, and nonunion (n=109). Long-term function, pain, and satisfaction were measured with Quick Disability of Arm, Shoulder, and Hand (QuickDASH), Oxford Shoulder Score and Visual Analogue Scale (n=87).

Results: Operative treatment: We could find no difference in functional score outcomes. The main outcome QuickDASH was excellent in both groups (median 0 nail vs. 2.26 plate). Surgery duration was shorter with intramedullary nail. We found 2 infections and 2 sensory affections in the plate group, and 1 infection and 1 sensory affection in the intramedullary nail group. There were 2 refractures in the nail group. Operative versus nonoperative treatment: there were no differences in functional outcomes between the operative and nonoperative groups. For the main outcome QuickDASH both groups scored excellently (median 1.12 operative vs. 0 nonoperative). The nonoperative group was more satisfied with the cosmetic result. There was 1 nonunion in the nonoperative group that later was operated.

Conclusions: Adolescents aged 12 to 18 years with displaced midshaft clavicular fractures show good long-term functional results after plate fixation, intramedullary nail, and nonoperative treatment. No additional benefit is demonstrated for surgery in our material. Nonoperatively treated patients are more satisfied with the cosmetic results. Little difference is seen between the operative methods in our study. We conclude that surgery should rarely be the choice of treatment for displaced midshaft clavicular fractures in adolescents.

Level Of Evidence: Level III study-retrospective comparative study.
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http://dx.doi.org/10.1097/BPO.0000000000001768DOI Listing
June 2021

Compared to conventional physiotherapy, does the use of an ankle trainer device after Weber B ankle fracture operation improve outcome and shorten hospital stay? A randomized controlled trial.

Clin Rehabil 2020 Aug 11;34(8):1040-1047. Epub 2020 Jun 11.

Department of Orthopaedic, Oslo University Hospital, Oslo, Norway.

Objective: To compare the functional outcomes and length of hospital stay for patients treated with conventional physiotherapy compared to a new ankle trainer device after Weber B ankle fractures.

Design: The patients were randomized, and then followed up at 3, 6, 12 and 52 weeks by a blinded physiotherapist.

Setting: This study was done at a level 1 trauma centre.

Subjects: One hundred and forty consecutive patients with Weber B ankle fractures that were operated on were screened for eligibility, of whom 113 were included in the study.

Interventions: Conventional physiotherapy with stretching exercises, using a non-elastic band or using new ankle trainer.

Main Measures: Outcomes were evaluated with Olerud-Molander ankle score, Visual analogue scale for pain and ankle dorsiflexion at 3, 6, 12 and 52 weeks follow-up. Time of hospitalization and complications were registered.

Results: Superior Olerud-Molander ankle scores were observed at three weeks follow-up in the ankle trainer group 40.9 (10.8), compared to the conventional group 35.3 (14.2) ( = 0.021). At one-year follow-up, there was no difference between the groups ( = 0.386). The ankle trainer group had a shorter hospital stay with a mean 2.6 days (0.98) compared to 3.2 days (1.47) in the conventional group ( = 0.026).

Conclusion: The patients who were treated with the new ankle trainer device recovered more rapidly, evaluated by the Olerud-Molander ankle score and had a shorter stay in hospital compared to the conventional physiotherapy group. No between group differences could be observed at long-term follow-up.
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http://dx.doi.org/10.1177/0269215520929727DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7372581PMC
August 2020

Results After Percutaneous and Arthroscopically Assisted Osteosynthesis of Calcaneal Fractures.

Foot Ankle Int 2020 06 15;41(6):689-697. Epub 2020 May 15.

Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.

Background: Operative treatment of calcaneal fractures using the extensile lateral approach is associated with high rates of soft tissue complications. In the past years, there has been a trend toward less invasive surgical approaches. Percutaneous and arthroscopically assisted calcaneal osteosynthesis (PACO) combines the advantages of visualization of the posterior facet of the subtalar joint with a minimally invasive approach.

Methods: We conducted a follow-up of 25 patients with 26 calcaneal fractures (Sanders II and III), treated with PACO with a minimum follow-up of 12 months. The median age was 44 years (range, 21-72) and the follow-up period 15 months (12-33). Our clinical outcomes were the Manchester-Oxford Foot Questionnaire (MOxFQ), the Calcaneus Fracture Scoring System (CFSS), the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, the Short-Form-36 (SF-36), the visual analog scale (VAS) for pain, and the number of complications. Radiographs on follow-up were obtained to evaluate the reduction of the fractures as well as osteoarthritis of the subtalar joint.

Results: The median MOxFQ score was 26.6 (0-76.6), the CFSS score 85 (26-100), and the AOFAS score 85 (50-100). The VAS pain score was 0 (0-5.7) at rest and 4.1 (0-8.2) during activity. The Böhler angle improved from a mean (SD) of 3.5 (12.3) degrees preoperatively to 27.7 (10.5) degrees postoperatively. The follow-up radiographs showed subsidence of the fractures and a Böhler angle of 20.3 (12.9) degrees. There were no wound-healing complications. Two patients had additional surgery with screw removal due to prominent hardware.

Conclusion: Our results suggest that PACO gives good clinical outcomes and a low risk of complications in selected calcaneal fractures. Prospective long-term studies will be necessary to better document the potential advantages and limitations of this operating technique.

Level Of Evidence: Level IV, retrospective case series.
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http://dx.doi.org/10.1177/1071100720914856DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7294532PMC
June 2020

Two Cases of Periprosthetic Fracture After Surgery for Acute Midfoot Charcot.

J Foot Ankle Surg 2020 Mar - Apr;59(2):394-398

Surgeon, Section for Foot and Ankle Surgery, Department of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway.

Charcot neuroarthropathy is a rare condition that often results in deformity of the foot and ankle, with a high incidence of ulceration and a high risk of amputation. Traditionally, treatment of the acute stages of Charcot foot has been nonoperative until consolidation. Still, a large number of patients develop deformities, and early operative treatment of unstable Charcot feet has been suggested. To overcome some of the inherent challenges when operating on acute-stage Charcot feet, the superconstruct technique has been proposed. Early surgery for dislocated Charcot foot is sparingly described in the literature. To investigate the utility of the superconstruct technique for acute midfoot Charcot, we planned a prospective cohort study including patients with midfoot manifestation (Brodsky 1) in the active stages of the disease. Patients eligible for the study were treated with open surgery and midfoot arthrodesis using the superconstruct technique. In this report, we present the development of periprosthetic fractures related to early surgery using the superconstruct technique, possibly causing a more proximal Charcot manifestation in 2 patients with >24 months of follow-up. To our knowledge, such complications have been sparsely noted in the literature.
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http://dx.doi.org/10.1053/j.jfas.2019.02.007DOI Listing
January 2021

Open Reduction and Internal Fixation of Acute Lisfranc Fracture-Dislocation with Use of Dorsal Bridging Plates.

JBJS Essent Surg Tech 2019 Oct-Dec;9(4). Epub 2019 Nov 1.

Section for Foot and Ankle Surgery, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.

Lisfranc injuries consist of a wide spectrum of injuries, ranging from subtle injuries to severe fracture-dislocations. Injuries with instability of the tarsometatarsal, intercuneiform, or naviculocuneiform joints should be treated with anatomic reduction and stable fixation. The best method of fixation is debated. Transarticular screw fixation has the disadvantage of damaging the tarsometatarsal joints. Bridging the tarsometatarsal joints with use of low-profile locking plates avoids the placement of screws through the joint and potentially reduces the risk of posttraumatic arthritis. Primary arthrodesis of the 3 medial tarsometatarsal joints is also an option in treating Lisfranc injuries and has been shown to lead to better outcomes compared with transarticular screw fixation in ligamentous Lisfranc injuries. In this article, we show the technique of open reduction and internal fixation of Lisfranc fracture-dislocation with use of dorsal bridging locking plates. The following steps are presented in the video: (1) incision technique with use of a dorsomedial incision and a dorsolateral incision, (2) open reduction and temporary fixation of the tarsometatarsal joints with use of Kirschner wires, (3) confirmation of anatomic reduction of the tarsometatarsal joints with direct visualization and fluoroscopy, (4) fixation of the medial 3 tarsometatarsal joints with dorsal bridging locking plates, (5) placement of a "homerun" screw from the medial cuneiform to the base of the second metatarsal, (6) fixation of the fourth and fifth tarsometatarsal joints with Kirschner wires, and (7) checking of reduction and fixation with use of fluoroscopy and performance of wound closure. Postoperatively, the foot is kept non-weight-bearing in a below-the-knee cast for 6 weeks, followed by 6 weeks of protected weight-bearing in a walker boot. Any Kirschner wires fixating the fourth and fifth tarsometatarsal joints are removed 6 weeks postoperatively. We prefer to remove the dorsal bridging plates 4 to 6 months postoperatively. Anatomic reduction and stable fixation is associated with better functional outcomes. Hardware failure and loss of reduction are potential complications that can lead to worse outcomes.
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http://dx.doi.org/10.2106/JBJS.ST.19.00009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6974315PMC
November 2019

Tibial Nerve Palsy After Lateralizing Calcaneal Osteotomy.

Foot Ankle Spec 2019 Oct 30;12(5):426-431. Epub 2018 Nov 30.

Section for Foot and Ankle Surgery, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.

Lateralizing calcaneal osteotomy (LCO) is a common procedure used to correct hindfoot varus. Several complications have been described in the literature, but only a few articles describe tibial nerve palsy after this procedure. Our hypothesis was that tibial nerve palsy is a common complication after LCO. A retrospective study of patients undergoing LCO for hindfoot varus between 2007 and 2013 was performed. A total of 15 patients (18 feet) were included in the study. The patients were examined for tibial nerve deficit, and all the patients were examined with a computed tomography (CT) scan of both feet. Patients with a preexisting neurological disease were excluded. The primary outcome was tibial nerve palsy, and the secondary outcomes were reduction of the tarsal tunnel volume, the distance from subtalar joint to the osteotomy, and the lateral step at the osteotomy evaluated by CT scans. Three of the 18 feet examined had tibial nerve palsy at a mean follow-up of 51 months. The mean reduction in tarsal tunnel volume when comparing the contralateral nonoperated foot to the foot operated with LCO was 2732 mm in the group without neurological deficit and 2152 mm in the group with neurological deficit (P = .60). 3 of 18 feet had tibial palsy as a complication to LCO. We were not able to show that a larger decrease in the tarsal tunnel volume, a more anterior calcaneal osteotomy, or a larger lateral shift of the osteotomy is associated with tibial nerve palsy. Level IV: Retrospective case series.
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http://dx.doi.org/10.1177/1938640018816363DOI Listing
October 2019

Proximal Medial Gastrocnemius Recession and Stretching Versus Stretching as Treatment of Chronic Plantar Heel Pain.

Foot Ankle Int 2018 Dec 22;39(12):1423-1431. Epub 2018 Aug 22.

2 Section for Foot and Ankle Surgery, Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.

Background:: Plantar heel pain is a common disorder that can lead to substantial pain and disability. Gastrocnemius recession has been described as an operative treatment option, but there is a lack of prospective clinical and biomechanical outcome data. The aim of this study was to evaluate the clinical and biomechanical outcomes of gastrocnemius recession and stretching compared with a stretching exercise protocol for patients with plantar heel pain lasting more than 12 months.

Methods:: Forty patients with plantar heel pain lasting more than 1 year were randomized to a home stretching exercise program only or to surgery consisting of a proximal medial gastrocnemius recession in addition to stretching exercises. The main outcome was the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score at 12 months. Secondary clinical outcomes were the Short Form-36 (SF-36) and visual analogue scale (VAS) pain scores. The biomechanical outcome parameters were ankle dorsiflexion, Achilles function evaluated by a test battery with 6 independent tests, and plantar pressure evaluated by pedobarography. All data were obtained at baseline and at 12-month follow-up.

Results:: The AOFAS score increased from 59.5 (42-76) to 88.0 (50-100; P < .001) for the operative group and from 52.5 (37-73) to 65.5 (31-88; P = .138) for the nonoperative group. The AOFAS, VAS pain, and SF-36 scores were significantly better in the operative compared with the nonoperative group at 12-month follow-up ( P < .05). Ankle dorsiflexion increased from 6 degrees (-3 to 15) to 10.5 degrees (0 to 23; P < .001). No between-group difference was observed for Achilles function at follow-up. The average forefoot plantar pressure for the operative group increased from 536 KPa (306-708) to 642 KPa (384-885) at follow-up ( P < .001).

Conclusion:: Proximal medial gastrocnemius recession with a stretching program was a safe and efficient method of treating chronic plantar heel pain.

Level Of Evidence:: Level 1, randomized clinical trial.
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http://dx.doi.org/10.1177/1071100718794659DOI Listing
December 2018

Validation of a New Device for Measuring Isolated Gastrocnemius Contracture and Evaluation of the Reliability of the Silfverskiöld Test.

Foot Ankle Int 2018 08 20;39(8):960-965. Epub 2018 Apr 20.

2 Section for Foot and Ankle Surgery, Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway.

Background: Important aspects on the diagnostics of isolated gastrocnemius contractures (IGCs) have been poorly described. This study was designed to validate a new ankle range of motion (ROM) measuring device for diagnosing an IGC. In addition, we wanted to investigate the reliability of the clinical Silfverskiöld test.

Methods: Twelve health care personnel (24 feet) were examined by 4 testers on 3 different occasions for the reliability testing of the new ankle ROM measuring device. The same participants were examined using the Silfverskiöld test to examine the reliability of the clinical test. Eleven patients (15 feet) with IGC were examined before gastrocnemius recession, immediately after surgery, and 3 months after surgery to examine the validity and responsiveness of the ankle ROM device.

Results: An intraclass correlation coefficient (ICC) >0.85 was found for both inter- and intrarater reliability for the new ankle ROM device. The device confirmed an IGC in 13 of 15 feet before surgery and 3 of 13 feet at 3-month follow-up. At baseline, the measured ankle dorsiflexion was median 3 degrees with the knee in extension, which increased to 10 degrees ( P < .001) immediately after surgery and 12 degrees ( P = .003) at 3-month follow-up. ICC values of 0.230 to 0.791 were observed for the inter- and intrarater reliability testing of the clinical Silfverskiöld test.

Conclusion: The new ankle ROM measuring device was reliable and responsive for detecting IGC. The Silfverskiöld test had poor inter- and intrarater reliability. Level of evidence Level II, prospective cohort study.
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http://dx.doi.org/10.1177/1071100718770386DOI Listing
August 2018

Endoscopic Transfer of Flexor Hallucis Longus Tendon for Chronic Achilles Tendon Rupture: Technical Aspects and Short-Time Experiences.

Foot Ankle Spec 2018 Oct 17;11(5):461-466. Epub 2018 Jan 17.

Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway (EEH, KHH, AHS).

Background: Chronic Achilles tendon ruptures can lead to reduced power of plantar flexion in the ankle with impaired gait ability. The open 1- or 2-incision technique for flexor hallucis longus transfer has proven good functional outcome but has the disadvantage of relatively extensive surgery performed at a vulnerable location. To reduce the risk of soft tissue problems, the flexor hallucis longus transfer can be performed endoscopically.

Material And Method: An endoscopic technique for flexor hallucis longus transfer is presented together with the experiences from the first six patients operated with this method.

Results: No wound healing problems or infections. Five of 6 patients managed single leg heel raise on the affected side 12 months after surgery.

Conclusion: The functional results are promising. The soft tissue dissection is minor, and no patients had postoperative wound healing problems or infection. Endoscopic flexor hallucis longus transfer may be an operative procedure that can be considered also in patients with potential wound healing problems.

Levels Of Evidence: Level IV: Technical note/case series without controls.
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http://dx.doi.org/10.1177/1938640017754234DOI Listing
October 2018

High Incidence of Recurrent Ulceration and Major Amputations Associated With Charcot Foot.

J Foot Ankle Surg 2018 Mar - Apr;57(2):301-304. Epub 2018 Jan 5.

Surgeon, Section for Foot and Ankle Surgery, Department of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway.

Few studies have evaluated the long-term clinical outcomes of Charcot foot. The present study evaluated the long-term effects of Charcot foot in a population treated with early weightbearing in a removable Charcot restraint orthotic walker. A retrospective study of 62 consecutive patients (74 feet) treated for Charcot foot from January 2003 to March 2014 was conducted. Of the 74 affected feet, 48 (64.9%) had developed an ulcer. The total amputation rate was 25.7% (19 feet), and 11 feet (14.9%) underwent major amputations. The mortality rate was 19.4% (12 patients). Low Short-Form 36-item scores for all subcomponents were found. The major amputation rate was significantly greater for hindfoot than for midfoot manifestations. Charcot foot results in a high risk of chronic ulceration. The hindfoot Charcot manifestation was associated with a high rate of major amputations. Early weightbearing in a Charcot restraint orthotic walker as treatment of Charcot foot was not supported by the results from the present study.
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http://dx.doi.org/10.1053/j.jfas.2017.10.008DOI Listing
September 2018

Clinical and Functional Outcomes of Gastrocnemius Recession for Chronic Achilles Tendinopathy.

Foot Ankle Int 2016 Oct 12;37(10):1091-1097. Epub 2016 Sep 12.

Section for Foot and Ankle Surgery, Department of Orthopaedic Surgery, Oslo University Hospital Ullevål, Oslo, Norway.

Background: Although gastrocnemius recession has been proposed and used in the treatment of chronic noninsertional Achilles tendinopathy, only weak evidence exists to support this operative indication. The purpose of our study was to assess the clinical and functional outcomes of patients treated with gastrocnemius recession at 2 institutions for this problem.

Methods: Thirty-four patients were identified through our medical records and asked to participate in this study. Thirty patients (35 legs) responded to the invitation. Sixteen patients were eligible for clinical follow-up, and 14 patients responded by letter or telephone interview. Two patients did not want to participate, and 2 patients could not be reached. Data were collected by a satisfaction questionnaire, the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire, a visual analog scale (VAS) for pain, a functional test battery, and a clinical examination.

Results: A subgroup with preoperative data (n = 8) showed an increase in the mean VISA-A score from 39.5 to 91.9. The mean overall VISA-A score (n = 30) was 91.4 at follow-up. The mean VAS for pain score when walking decreased from 7.5 before surgery to 0.8 after surgery. Twenty-eight of 30 patients reported that they were satisfied with their results after surgery. Functional testing showed no difference in gastrocnemius-soleus function between the operated and nonoperated leg (n = 10).

Conclusion: The findings support the promising results from other studies regarding gastrocnemius recession as an effective and safe way of treating chronic Achilles tendinopathy. The patients recovered both in terms of pain and function.

Level Of Evidence: Level IV, retrospective case series.
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http://dx.doi.org/10.1177/1071100716667445DOI Listing
October 2016

Results after gastrocnemius recession in 73 patients.

Foot Ankle Surg 2014 Dec 24;20(4):272-5. Epub 2014 Jul 24.

Oslo University Hospital Ullevaal, Department of Orthopaedic Surgery, Norway. Electronic address:

Background: Very few studies describe the clinical results and complications following the surgical procedure of gastrocnemius recession.

Purpose: To survey the patient reported outcomes in patients operated with gastrocnemius recession as single procedure for various foot conditions.

Material And Methods: 93 patients operated with gastrocnemius recession as single procedure between 2006 and 2011 were detected in the database. 73 patients responded to the invitation for study participation. Questionnaires containing patient reported satisfaction, complications, plantar flexion power and visual analog pain score were used for evaluation of the postoperative result.

Results: 45/73 (62%) patients reported a good or excellent result. 8/73 (11%) patients reported a significant postoperative complication. 16/73 (22%) patients noted reduced or severely reduced plantar flexion power after surgery. VAS pain score significantly decreased from 7.0 before surgery to 1.8 (p=0.015) after surgery for patients with plantar fasciitis (n=18) and from 5.6 to 2.3 (p<0.01) for patients with metatarsalgia (n=28).

Conclusion: Patients treated with gastrocnemius recession for plantar fasciitis demonstrated good clinical results. The complication rate was higher than reported by others.
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http://dx.doi.org/10.1016/j.fas.2014.07.004DOI Listing
December 2014

Posterior tibial tendon transfer improves function for foot drop after knee dislocation.

Clin Orthop Relat Res 2014 Sep;472(9):2637-43

Department of Orthopaedic Surgery, Oslo University Hospital, Ullevaal, Box 4950 Nydalen, 0424, Oslo, Norway.

Background: Knee dislocation may be associated with an injury to the common peroneal nerve with a subsequent foot drop. Previous studies have demonstrated good functional results after posterior tibial tendon transfer in patients with foot drop. No studies, to our knowledge, have focused exclusively on knee dislocation as the cause of common peroneal nerve injury leading to foot drop.

Questions/purposes: We determined the percentage of patients developing common peroneal nerve paresis after knee dislocation, the symptom improvement rate in these patients, and patient-reported outcomes (American Orthopaedic Foot and Ankle Society [AOFAS] ankle-hindfoot score), ankle dorsiflexion strength, and ROM in patients with no symptom improvement treated with posterior tibial tendon transfer.

Methods: Two hundred forty-seven patients with knee dislocation, defined as an injury to both the ACL and PCL with an additional injury to the lateral and/or medial ligaments (Schenck Classification II to IV), were registered in a single institution's database between 1996 and 2011. The database was queried for the frequency of documented injuries to the common peroneal nerve and, among those, the frequency of spontaneous resolution after this injury. Patients demonstrating no active dorsiflexion 12 months after injury generally were offered posterior tibial tendon transfer. Postoperatively, patients were evaluated for AOFAS score, ankle dorsiflexion strength, and ROM.

Results: Forty-three patients (17%) had a common peroneal nerve paresis at admission. At 1-year followup, 15 of 43 patients (35%) had experienced symptom improvement. One patient experienced spontaneous improvement later than 1 year after injury. One patient was lost to followup. A below-knee amputation was performed in one patient due to the initial trauma. Seven patients were satisfied with their function using a brace or had medical contraindications to surgical treatment, while four patients refused the proposed operation with a tendon transfer, leaving 14 patients treated with posterior tibial tendon transfer. In the 12 patients available for evaluation, mean AOFAS score was 91 of 100. Mean (± SD) dorsiflexion strength was 118 (± 55) Nm on the operated side and 284 (± 94) Nm on the unaffected side (p < 0.001). Mean ROM was 67° (± 15°) on the operated side and 93° (± 14°) on the unaffected side (p < 0.001).

Conclusions: Based on these findings, we recommend posterior tibial tendon transfer for treatment of foot drop that persists at least 1 year after knee dislocation.

Level Of Evidence: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1007/s11999-014-3533-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4117907PMC
September 2014
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